2023-2024 Detectives (2/3rd) Registration

Student Name

Birthdate

Grade in School

Address

Parent/Guardian Name

Cell Phone

This address will receive a confirmation email

Emergency Contact (if different than parent/guardian)

Relationship

Emergency Contact Phone

Invited by

Church

Special Consideration(s)

Siblings also attending

I give my permission for the above student to participate in program activities and games, and I realize that even when carefully supervised there is a chance that he/she could get hurt.

By checking this box I give my permission for the above statement.

I will not hold the church and/or its representatives liable for injury, and I give my permission for the above named child to be treated in case of an emergency.

By checking this box I give my permission for the above statement.

Yearly Dues & Handbook

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Rock Prairie Church, 421 Ash Street, Tipton, IN 46072
(765) 675-4588
Wednesdays from 6:00-7:30 p.m.
Please fill out this form and click submit.

2023-2024 Detectives (2/3rd) Registration

Description

Please Fix the Following